Provider Demographics
NPI:1063854610
Name:MCCOY, MATTHEW BLAIR (OD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:BLAIR
Last Name:MCCOY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1229 E SEMINOLE ST STE 430
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2227
Mailing Address - Country:US
Mailing Address - Phone:417-820-9393
Mailing Address - Fax:
Practice Address - Street 1:1229 E SEMINOLE ST STE 430
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2227
Practice Address - Country:US
Practice Address - Phone:417-820-9393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-24
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1929DT152W00000X
SC1779152W00000X
MO2018040909152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD17792Medicaid